Annals of Case Reports Agashe S, et al. Ann Case Report 14: 559. Case Report DOI: 10.29011/2574-7754/100559 A Case of Moyamoya Physiology Presenting as Abdominal Pain Shruti Agashe*, Rajan Gadhia, Ejaz Janjua Department of Neurology, Houston Methodist Hospital, Houston, Texas, USA

*Corresponding author: Shruti Agashe, Department of Neurology, Houston Methodist Hospital, Houston, Texas, 6565 Fannin St, Houston, Texas 77030, USA. Email: [email protected] Citation: Agashe S, Rajan Gadhia R, Ejaz Janjua E (2020) A Case of Moyamoya Physiology Presenting as Abdominal Pain. Ann Case Report 14: 559. DOI: 10.29011/2574-7754/100559 Received Date: 23 September, 2020; Accepted Date: 21 October, 2020; Published Date: 27 October, 2020 Case Introduction An extensive workup for hypercoagulability, vasculitis and malignancy was unremarkable (Figure 1). 33 y.o. left handed male with a medical history significant for hypertension (HTN) who presented for further evaluation of abdominal discomfort. He reported a history of chronic postprandial periumbilical discomfort ongoing for eighteen months. He denied any diarrhea, hematochezia, melena or vomiting. His noted a weight loss of 30 lbs in less than a year that he attributed to loss of appetite secondary to pain. He was diagnosed with uncontrolled HTN in 2013. Family history is significant for hypertension in parents when in their 60s. Patient does not smoke, consume alcohol or use illicit drugs. Pertinent Exam Findings On exam, patient was noted to have an abdominal , and 4/6 systolic loudest in the second intercostal space. Cognition was intact, and no focal neurological deficits were observed. Pertinent Workup CT angiography of abdomen showed extensive noncalcified soft tissue plaques causing severe stenosis of the distal aorta, extending into bilateral common iliacs, moderate stenosis of right common iliac, occlusion of the celiac , superior and inferior mesentaric arteries, right hypogastric and two right renal arteries and an irregular, highly stenotic left renal . Given the extent of disease and carotid bruit on examination, vascular imaging of brain and chest was performed. CT angiography head and neck showed 50% stenosis of the left and right common carotid arteries and occluded bilateral Internal Carotid Arteries (ICA). The right Figure 1: Moyamoya physiology- Images show Reconstruction of vertebral artery was patent, and left vertebral artery was occluded. Abdominal Aorta and Multiple collaterals noted on CTA abdomen The entire intracranial circulation was supplied by the right and CTA head. vertebral artery and collateral flow through the external carotid arteries. Multiple collateral arteries were present along the neck, Discussion suggesting chronic ICA stenoses. CTA head in addition showed The findings were consistent with an atypical presentation that bilateral M1 Middle Cerebral Artery (MCA) segments and of systemic large vessel vasculopathy, with significant extracranial A1 Anterior Cerebral Artery (ACA) segments were not seen. and intracranial vasculopathy and imaging features consistent with Prominent bilateral lenticulostriate collaterals were present. Moyamoya physiology.

1 Volume 14; Issue 07 Ann Case Rep, an open access journal ISSN: 2574-7754